First Impressions and how to avoid them

A mental health professional could perform a few hundred new assessments each year. Every time, they use their first impressions to get to know the patient and to help form a plan with them. But can we really form an accurate picture of someone over such a short period – and if not, what can we do about it?

First things first

In his book What the Dog Saw, Malcolm Gladwell recounts his meeting with a young man called Nolan Myers. A recent graduate of Harvard, Nolan was being headhunted by various prestigious companies. Recruiters were singling him out from thousands of potential employees for special attention. Managing directors were ringing him personally.

But Gladwell just couldn’t put his finger on why they seemed so interested in Nolan. Sure, his CV was top notch, but that wasn’t unusual. There was just something about him that convinced people that he was worth hiring, even after just a short chat. Gladwell understood how these businessmen felt – though he’d only spent an hour drinking coffee with Nolan, he somehow had an inkling that the kid would be good at his job.

The trust we place in “gut feeling” is an interesting phenomenon. None of these company directors, and certainly not Gladwell, had any idea how Nolan acted with people outside of an interview room. They didn’t have the foggiest idea how he solved problems at work, how he led a team or how he dealt with clients. But based on how they felt about him, they assumed he’d be good at all of those things. By all logic, this was an incomprehensible gamble. They were using their first impression of Nolan to infer a hell of a lot.

Gladwell also discusses how first impressions can still influence how we feel about someone after months of knowing them. In one study, just two seconds of silent footage of a teacher giving a lesson was enough for people to form a judgement of the ability of that teacher – judgements which were strikingly similar to judgements of those teachers by their own students after a year of lessons. Unless you believe that you really can judge how good a teacher is based on two seconds of silent footage, what you’re seeing here is the overriding effect of a first impression.

In another experiment, participants were asked to decide whether they’d hire a candidate after being shown footage of just the first few seconds of their interview – the candidate approaching the panel and shaking hands. Again, judgements of each candidate’s suitability for the job were remarkably similar to judgments made when the whole interview was taken into account. That first impression is hard to shake off.

Reflex impressions

There are various psychological principles that might help us explain the power of first impressions.

Perhaps the most simplistic explanation is the primacy effect. Things that we learn first (and things that we learn last – the recency effect) seem to be more salient to us. So the theory goes, the first impressions have longer to burrow into our long-term memories whilst the newest impressions are still fresh in our short-term memories. But that doesn’t seem quite sophisticated enough an answer.

Tied in with the primacy effect, though, is the anchoring effect. When you meet someone for the first time, you set a mark for them in terms of personality. Every subsequent interaction with that person is then judged in comparison with that mark. If you’re nervous and stuttering in your interview for a job, but manage to get the job anyway, the interview panel will to an extent always see you in that light. Even if you’re confident and energetic every day for a year afterwards, they may still judge you based on their anchor of you – seeing you as “more confident than usual”.

Likewise, the halo effect explains how people with one or two obviously good (or bad) qualities are assumed to have other characteristics of the same quality. Good looking people are assumed to be more generous, caring and trustworthy than others, even when the people doing the judging have no firm evidence to back that up. Perhaps it was this effect which made it possible to form stable judgements of teachers in just two seconds.

A more comprehensive theory of irrational judgements of people can be found in schema. We all have thousands of schema in our heads, on every topic from white people to motorbikes to the moon. They’re mental pocketbooks of information, a form of heuristic, that we can use to make thinking a whole lot less effortful. When we see a motorbike, for example, we automatically use our motorbike schema to assume that it has two wheels, you can ride it, and it’ll hurt if it hits you at 60 miles an hour. This process saves us checking every motorbike we see to make sure it’s not made of jelly.

Unfortunately, taking mental shortcuts can lead us to make mistakes. Black people are still more likely to be seen as more dangerous and less hard working than white people, because those are attributes that society has stored in its schema of black people. They aren’t conscious assumptions, more automatic cognitive processes, in this case due to (amongst other things) unfairly negative media representation.

In relation to mental health

It’s not hard to see how these biases can creep in when we assess a new patient. With limited time and under pressure from the system, we find it all too easy to let our first impressions hold sway. In times of crisis, patients will present at their most vulnerable, their most disorganised, their most unwell. If we’re not careful the primacy and anchoring effects will take hold, we’ll think that’s how they’ve always been and how they usually will be.

And sadly, if the patient is young, black and male, they’ll fit easily into our society’s schema of unemployed cannabis users. But there’s every chance that stereotype won’t apply to them.

So how can we ensure these biases don’t get the better of us?

Not for the first time, continuity of care seems important. If we build services and work within those services in ways that encourage and reward stable relationships with patients, the number of first impressions that actually need to be made will drop. The longer we spend looking after a patient, the more likely it is that we can get to know them thoroughly and watch our halo and schema biases fall away.

If referrals or staff changes do need to be made, making sure the referral is comprehensive is vital. Including as much information as possible, and discussing the patient face-to-face, might both be good ways to avoid the new team making assumptions about their patient.

However, I think a certain tenet of humanistic psychology might be the most important tool we have to combat these biases – taking a “view from nowhere”. This means that we should make a special effort to recognise that we’re all hugely biased in our viewpoints, and that the only way we can truly understand the entirety of someone else’s experience is to attempt to suspend those biases through open-mindedness and practice.

I can’t remember how many blogs I have ended like this, but the best remedy seems to be to let patients speak, to hear what they have to say with an unassuming ear and to check that you understood them right.

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About Alex LangfordI am a psychiatry trainee based in South East London. Before I went into psychiatry, I used to be a general medical doctor, and I also have a BSc in psychology.
I'm particularly interested in improving the public face of psychiatry, evidence based medicine, teaching and patient rights.
Don't mention cricket unless you've got the next fortnight free to discuss it.

9 Responses to First Impressions and how to avoid them

My first impression of the psychiatrists I have seen is the way they are dressed. One had a suit and waistcoat, which was so smart compared to my jeans and t shirt. The waistcoat had several buttons done up. And he had a massive expensive watch. It made me think ‘ This man’s a wealthy professional.’ It felt a bit out of place, as if it were meant to create distance. I believe that was his intention.
He used to surreptitiously tilt his notes at an angle just so you couldn’t read them, which he knew you wanted to. Getting things off to the right footing, like someone pulling you off balance.
I would feel much happier seeing someone who looks like they have been dragged through a hedge backwards
He liked to keep it short and sweet because he was worried you were going to ask a question he wouldn’t know the answer to, so he was impatient to get you out the door. He also had this self-reflecting aspect to his voice as if he were talking to himself as he was talking to you, so that he could be conscious of himself talking to you and run a kind of simultaneous commentary on it. This made me think he was very clever, which was an impression he left with many people……..
It also made me think though that he was maybe a bit vain and that it was beneath him to sink to the level of the patient. He had a very good knowledge of how to close down opportunities for expression, as sensitive as antennae. So why would he want to do that?
Other doctors I have met have been more down to earth and have genuine respect and concern, and are interested in what you think.

For me, I feel almost universal fear and hate. That is probably more usual than feeling universal love, which is for stupid people, or mothers with young children. I am far from alone, I suspect. My outlook is pessimistic, which I rather suspect most psychiatrists share, so.quite how people with morbid interests are supposed to make you feel better I don’t know. That is probably why they are so odd.

How much longer will this terrible blog continue? It’s like you’re some inadequate pastiche of Goldacre, Kahnemann, Levitt, etc, just reciting already popularised knowledge of psychology and statistics. What next, a Ronson-esque post about how a little bit of psychopathy is useful and how the word ‘psychopath’ is misused? Boring.

I like Alex Langford’s blogs. He is making an attempt to communicate the work of a psychiatrist to the public which is ridiculously difficult. He is also open minded and brave enough to want to learn from patients and elicit their thoughts, feelings and experiences so that he can heal people.

I think one problem that people may find with psychiatrists, particularly consultants, is that they appear to know too much. Once or twice I have had medical students in on outpatient appointments and you can see that they are not remotely interested in the patient, but hang off every word of the consultant. So who is the appointment actually for?
Inadvertantly i saw that the medical students didn’t think very much of patients, probably because they were not the sort of people one finds at medical.schools. And because the consultant was more interested in impressing his proteges than meeting the ‘patient’ he failed to correct their attitude, whereby revealing his own. Probably in every hospital you go to, psychiatric or not, when the consultant arrives staff practically fling themselves at them, and when they are gone you can see the disappointment of being left with the rubbish patients.

Hi Alex, thanks for the kind reminder that we’re cognitively fallible. I am a Trainee Clinical Psychologist and fellow blogger (www.racereflections.co.uk). I am particularly interested in how stereotyping and labeling processes and biases can affect not only the care that patients receive but also how they present and/or what presents in clinician-patient encounter or interaction which I see as a co-creation. Does that make sense? Wondered if you had any thoughts/experiences related to that …just curious really.

Thanks for the thoughts. I’m on nights so my brain is a haze, but I’d say the most prominent biases we face in the interaction are the obvious ones – race and gender. We’re more likely to focus on cannabis use and drug concordance with young black men and on self harm and sexual abuse with white women.

Did you have any personal examples of other biases in the construction of an interaction?

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I am a psychiatry trainee based in South East London. Before I went into psychiatry, I used to be a general medical doctor, and I also have a BSc in psychology.
I'm particularly interested in improving the public face of psychiatry, evidence based medicine, teaching and patient rights.
Don't mention cricket unless you've got the next fortnight free to discuss it.